Attachment D.3 - Nutrition _ Food Satisfaction Survey.pdf
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- Solicitation number
- 36C25022Q0346
About this file
This document contains a nutrition and food services satisfaction survey and details of a related federal contract opportunity. The satisfaction survey collects feedback from patients on meals provided at a Department of Veterans Affairs facility, asking them to rate taste, appearance, variety, temperature consistency, timeliness of service, and staff courtesy using a five-point scale. It also includes an optional comment section.
The related federal contract opportunity is a set-aside solicitation for domiciliary food services at the Richard L. Roudebush VA Medical Center in Indianapolis. The requirement calls for performance of food services in accordance with the attached statement of work. It is a verified service-disabled veteran-owned small business set-aside being conducted by the VA Veterans Health Administration VISN 10. Interested parties should respond by the specified due date to be considered for award, which is also indicated.
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Text version
OMB
2900-0770 Estimated Burden: 2 min.
Nutrition & Food Services Satisfaction Survey “Because We Care”
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.
The purpose of this data collection is to determine the level of patient satisfaction and quality of service. Response to this survey is voluntary and failure to participate will not affect any benefits to which you may be entitled.
Great Nutrition……….America’s Healthy Choice VA Form 10-0498 NOV 2012
Nutrition & Food Services
Strongly
Agree
Agree
Neutral
Disagree
Strongly Disagree
My meals taste good.
My meals look good.
My meals offer variety.
Cold food is served cold enough.
Hot food is served hot enough.
My meals are served in a timely manner.
Nutrition employees are polite and courteous.
I understand my prescribed diet.
My overall rating of Nutrition and Food Services excellent.
is
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
5 4 3 2 1
Comments or Suggestions?
(optional information)
Name: Room#
File details come from the government source that posted it. Updated .